Title Page
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Conducted on
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Prepared by
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Weitsman Site Location:
- Albany
- Alleghany
- Binghamton
- Brant
- Hornell
- Ithaca New Steel
- Ithaca Scrap
- Jamestown
- New Castle
- Owego Main
- Owego Shredder
- Rochester
- Scranton
- Syracuse
- Watertown
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Today's Date
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Time this report is filled out:
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Employee's Name (First, Last)
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Employee's Date of Birth:
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Employee's Address:
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Employee's Gender
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Employee's Age:
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Employee's Cell Phone Number:
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Employee's Home Phone Number:
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Employee's job description:
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Date and Time of Accident:
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Number of hours employee worked in the shift this accident occurred:
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Number of hours employee worked in the week of the accident:
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Name of Person who reported this accident?
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Was a Weitsman-owned Vehicle Involved in this accident?
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Vehicle Year
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Vehicle Make/Model
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Vehicle License Plate (State and Number)
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Pictures taken of:
- Injury
- Location of injury
- Vehicle
- Item that caused injury
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What does the employee report they were doing just before the injury occurred?
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How did the injury occur?
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Where (what part of the plant or yard) does the employee report the injury occurred?
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Did the injury occur in an area where the employee is normally allowed?
List witnesses to the event and contact phone number. If there are no witnesses, list "NONE"
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Witness Name (or None)
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Witness Phone Number
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Describe the injury:
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Which side of the body did the injury occur:
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Part of the body where injury occurred (Check as many parts as apply):
- Head
- Face
- Eye
- Mouth
- Ear
- Neck
- Shoulder
- Arm
- Elbow
- Hand
- Finger/Fingers/Thumb
- Wrist
- Torso
- Leg
- Knee
- Ankle
- Foot
- Toe
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Describe the object or substance that caused the injury:
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Did the employee request medical evaluation or treatment for the injury?
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Name of Doctor, Urgent Care, or Hospital employee is going to:
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Address or Town of Hospital:
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Is this a hospital emergency room?
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Was employee transported by ambulance to the hospital?
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If employee refuses medical treatment, they must read the statements below and sign at the end of the statements.
- I refuse medical treatment and /or observation for the injury described above.
- I am aware that at a later time, I may request authorization to seek medical treatment and/or observation for the above described injury from my employer, through my Supervisor or the Human Resources Department.
- I am aware that at a later time, I may request authorization to seek medical treatment and/or observation for the above described injury from my employer, through my Supervisor or the Human Resources Department.
- I acknowledge that by declining medical treatment at this time, my employer will not be responsible for any medical expenses or lost wages, unless determined and directed by a medical doctor at a later time.
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Employee's Signature only if employee is refusing medical treatment at this time.
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Was employee hospitalized overnight for inpatient treatment?
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Is the employee's injury a fractured bone?
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Did the employee receive stitches?
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Did the employee lose consciousness?
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Did the doctor prescribe a prescription medication?
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Did the doctor advise time off of work?
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Until what date?
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Did the doctor advise work restrictions?
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Can your location provide work for this employee within their medical restrictions?
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Report prepared by (Your Name):
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Job title of person who prepared report:
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Telephone of person who prepared report:
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Signature of person who prepared report:
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Injured employee's signature:
